Provider Demographics
NPI:1699812206
Name:MADDOCK, SANDRA STEVENSON (MSS)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:STEVENSON
Last Name:MADDOCK
Suffix:
Gender:F
Credentials:MSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 WEST UNIVERSITY
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1938
Mailing Address - Country:US
Mailing Address - Phone:248-608-1482
Mailing Address - Fax:248-652-9930
Practice Address - Street 1:410 WEST UNIVERSITY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1938
Practice Address - Country:US
Practice Address - Phone:248-608-1482
Practice Address - Fax:248-652-9930
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010771501041C0700X
DE00002271041C0700X
GACSW0013981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical